PERINATAL OUTCOMES IN STAGE II FETAL GROWTH RESTRICTION - PowerPoint Presentation

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PERINATAL OUTCOMES IN STAGE II FETAL GROWTH RESTRICTION

Dr Nibedita Maharana, Dr Sweta Singh, Dr Jasmina Begum, Dr Subarna MitraDepartment of Obstetrics and GynaecologyAll India Institute of Medical Sciences, Bhubaneswar

INTRODUCTION

Doppler velocimetry is used extensively in prenatal assessment of

fetal well-being in

high risk pregnancies

1

Fetal

growth restriction (FGR)

, a subset of high risk pregnancy, is a common cause of

perinatal morbidity and mortality,

especially in developing countries

2

The

Stage based management protocol

(Barcelona protocol)

for

FGR

was first proposed in 2014

2

In this,

Stage II FGR

with absent-end diastolic velocity

(AEDV) in Umbilical Artery (UA)

indicates

severe

p

lacental

i

nsufficiency,

which

may lead to

fetal

death

, stillbirth, neonatal complications

like respiratory distress syndrome, necrotizing enterocolitis, intraventricular haemorrhage, perinatal mortality, and long-term neurodevelopmental impairment.

2

,3

OBJECTIVES

Against this background, the objective of our case series is:To describe the perinatal outcomes in the subset of women with Stage II FGR diagnosed antenatally

To describe the associated maternal complicating factors in these women with Stage II FGR

METHODOLOGY

Study setting :Department of Obstetrics & Gynaecology, AIIMS BBSR Study design:

Retrospective cohort studyStudy duration: From July 2019 to January 2020 (6 months)Inclusion criteria: All women with AEDF on UA Doppler after standardized ultrasound examination at AIIMS BBSR

Exclusion criteria: Incomplete data Ethics clearance: Not deemed necessaryProtocol: Standard protocol of frequent fetal Doppler assessment

,

administration of corticosteroids

( 4 doses of dexamethasone if terminated before 36 week)

and magnesium sulphate

( if terminated before 34 week) before delivery was followed in all cases

RESULTS 9 women with Stage II FGR were included in this analysis

Case 1

Case 2

Case 3

Case 4

Case 5

Case 6

Case 7

Case 8

Case 9

Age (year)

31

32

30

30

30

20

23

25

34

Obstetric Score

G1

G1

G4A3

G1

G1

G2A1

G1

G1

G2A1

Associated pregnancy complications

Chronic HTN with superimposed PE, FGR

PE,

FGR

Chronic HTN with superimposed PE, FGR

Chronic HTN with superimposed PE

FGR

Chronic HTN, PE, FGR

HTN retinopathy,

Diabetes mellitus

FGR, PE

GDM,

FGR,

TB meningitis

FGR, Scrub typhus,

Beta Thalassemia trait

FGR

Overt DM

Epilepsy

GA at first detection of AEDF (week)

28

29

29

+2

28

+1

27

+5

35

+5

34

32

+2

31

+2

GA at reversal of flow (week)

31

+1

31

+6

30

+2

29

+5

29

+2

-

33

32

+4

R

ESULTS…

Case 1

Case 2

Case 3

Case 4

Case 5

Case 6

Case 7

Case 8

Case 9

GA ( weeks) at termination of pregnancy

31

+1

31

+6

30

+3

29

+5

29

+2

36

34

+2

33

32

+5

Birth weight of baby (gram)

830

840

1025

960

840

1775

920

1500

1050

Apgar score at 1, 5 min

5, 8

6, 7

6, 8

6, 8

4, 7

9, 9

9, 10

7, 9

7, 9

NICU admission (days)

42

40

28

34

38

2

33

7

22

Follow up

(month)

3

3

3

3

3

3

3

3

3

Associated congenital malformations

Nil

Nil

Nil

Nil

Nil

Nil

Nil

Nil

Nil

RESULTS: SUMMARY

Nine (9) women with FGR Stage II

were analysed

The median gestation of

appearance of AEDF was

29.2 weeks

The average time from appearance of absence

to reversal of UA flow

was

1

weeks 6 days

Seven (7/9) cases

were terminated

before 34weeks

as there was reversal of end diastolic flow

FGR Stage II was associated with maternal:

C

hronic hypertension

(4/9 cases)

P

reeclampsia

( 2/9 cases)

GDM with TB meningitis

(1/9 case)

Scrub typhus with beta-thalassemia trait

(1/9 case)

Epilepsy with overt diabetes

(1/9 case)

R

ESULTS: SUMMARYIn all cases, the mode of termination was lower segment caesarean section

All babies had low birth weight

, contributing to longer NICU admission

E

xtremely low birth weight babies (<1000gram) :

5

/9 babies

V

ery low birth weight (<1500gram):

2

/9 babies

Low birth weight babies ( 1500-2500 gram):

2

/9 babies

The

mean NICU admission

for extremely low birth weight babies was

37.4 days

A

ll the babies were

followed up after 3 month age and found to be healthy

There were n

o neonatal deaths

No congenital anomalies

were detected in any of the babies

DISCUSSION

The

absence or reversal of end diastolic flow in the umbilical artery Doppler undoubtedly indicates a

high-risk

fetus

requiring intense

fetal

surveillance, judicious and expeditious delivery

4

Although immediate delivery may not be indicated, the consensus says

intensive

fetal

surveillance should be initiated

with

strong consideration given to early delivery

if conditions get worsened

Obstetric challenge in the management consists of ascertaining the

optimal time of delivery

by weighing the risks of prematurity against the risks of a potentially hostile intrauterine environment.

5

D

ISCUSSIONAbsent or reversed end diastolic flow in the umbilical artery

is associated with perinatal complication like intraventricular haemorrhage, bronchopulmonary dysplasia, respiratory distress syndrome, necrotizing enterocolitis, and long-term neurodevelopmental impairment

3

However

preterm birth

, spontaneous or iatrogenic, is also associated with a significant

increased risk of neonatal morbidity and mortality

6

Treatment with

antenatal corticosteroids

decreases RDS, and IVH in preterm infant, with a significant reduction in the incidence of neonatal necrotising enterocolitis and systemic infections in the first 48 hours of life, as well as reducing the need for respiratory support and NICU admission.

7

DISCUSSION

Intrauterine

fetal jeopardy as well as prematurity

are frequently associated with neurological outcomes like cerebral palsy and long term cognitive impairments

8

The risk of

cerebral palsy is increased by 30–80-fold in infants born before 30 weeks

compared to term infants.

9

We considered administration of

magnesium sulphate till 33

+6

weeks

as per NICE guidelines.

10

Though babies in our study were delivered preterm with a birth weight less than the desirable,

timely delivery and judicious administration of antenatal corticosteroid and magnesium sulphate

led to a better neonatal outcome

C

lose

fetal

surveillance

remained the key to the successful outcome.

CONCLUSION

Placental insufficiency due to maternal chronic hypertension

was the most frequent cause of FGR

The only known effective

treatment of

FGR

is delivery

, and, therefore, in order to improve the clinical outcome, a

timely recognition of

FGR

and an optimal timing of the delivery are crucial

T

he

gestational age at birth

also plays a fundamental role in the neonatal outcome in the case of

FGR

According to the evidence available today,

Doppler study of the umbilical arteries

(UAs) is the only test that has shown to

improve the outcome, reducing perinatal mortality and reducing obstetric interventions

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Kuo

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Thank you

!